Question 1

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

Accepted Answer

A)  The standard fees of indemnity health insurance plans, adjusted by region 
B)  The Medicare fee schedules used by other health plans, adjusted by region 
C)  Whichever amount is higher, the billed charge or the DFFS amount 
D)  Whichever amount is lower, the billed charge or the DFFS amount

Question 2

The two basic approaches that Medicaid uses to contract with health plans are open contracting and selective contracting. One true statement about these approaches to contracting is that:

Accepted Answer

A)  Open contracting requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP) 
B)  Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees 
C)  Selective contracting requires any health plan that meets the state's performance standards and the federal Medicaid requirements to enter into a Medicaid contract 
D)  Selective contracting requires health plans to bid competitively for Medicaid contracts

Question 3

If the Oconee Health Plan reimburses its specialty care physicians (SCPs) under a typical retainer method, then Oconee pays SCPs

Accepted Answer

A)  Aseparate amount for each service provided, and the payment amount is based solely on a resource-based relative value scale (RBRVS) 
B)  Aspecified fee that remains the same regardless of how much or how little time or effort is spent on the medical service performed 
C)  Aset amount each month, and Oconee reconciles its payment at periodic intervals on the basis of actual utilization 
D)  Aset amount of cash equivalent to a defined time period's expected reimbursable charges

Question 4

The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

Accepted Answer

A)  Most-favored- nation arrangement 
B)  Alimit on action 
C)  Aconsideration 
D)  An assignment

Question 5

The following statements describe two types of HMOs: The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP. The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO. Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management. Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits: The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug. The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug. To calculate its drug costs, Elm uses a pricing system known as:

Accepted Answer

A)  Estimated acquisition cost (EA
C)  
B)  Package rate cost (PR
C)  
C)  Actual acquisition cost (AA
C)  
D)  Wholesale acquisition cost (WA
C)

Question 6

Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

Accepted Answer

A)  Payments under the reimbursement method typically are not subject to any copayment or deductible requirements 
B)  Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges 
C)  Most major medical plans follow a service approach 
D)  Most current health plan prescription drug plans are service plans

Question 7

The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

Accepted Answer

A)  The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law. 
B)  The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA. 
C)  Both A and B 
D)  A only 
E)  B only
F) Neither A nor B

Question 8

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

Accepted Answer

A)  an antidisparagement clause 
B)  a low-enrollment guarantee clause 
C)  a retroactive enrollment changes clause 
D)  an eligibility guarantee clause

Question 9

A population's demographic factors--such as income levels, age, gender, race, and ethnicity--can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

Accepted Answer

A)  higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations 
B)  compared to other groups, young men are more likely to be attached to particular providers 
C)  a population with a high proportion of women typically requires more providers than does a population that is predominantly male 
D)  Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Question 10

From the following answer choices, choose the type of clause or provision described in this situation. The provider contract between Dr. Olin Norquist and the Granite Health Plan specifies a time period for the party who has breached the contract to remedy the problem and avoid termination of the contract.

Accepted Answer

A)  Cure provision 
B)  Hold-harmless provision 
C)  Evergreen clause 
D)  Exculpation clause

Question 11

Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits. The provider network that Shipwright uses to furnish services for its workers' compensation program will most likely

Accepted Answer

A)  Emphasize primary care and consist mostly of generalists 
B)  Focus treatment approaches on rapid recovery rather than cost 
C)  Offer workers' compensation beneficiaries the same types and levels of treatment that Shipwright's traditional network furnishes to group health plan members 
D)  Exempt participating providers from meeting standard credentialing requirements

Question 12

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

Accepted Answer

A)  provisions for marketing the plan's product 
B)  payment arrangements between the plan and the provider 
C)  verification of the plan's eligibility to do business 
D)  management of the contents of members' medical records

Question 13

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline. Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated. Autumn's method of reimbursing specialty providers can best be described as a

Accepted Answer

A)  Disease-specific arrangement 
B)  Contact capitation arrangement 
C)  Risk adjustment arrangement 
D)  Withhold arrangement

Question 14

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson's action is an example of a type of false billing procedure known as

Accepted Answer

A)  Cost shifting 
B)  Churning 
C)  Unbundling 
D)  Upcoding

Question 15

In most states, workers' compensation is first-dollar and last-dollar coverage, which means that workers' compensation programs

Accepted Answer

A)  Can place limits on the benefits they will pay for a given claim 
B)  Can deny coverage for work-related illness or injury if the employer is not at fault 
C)  Must pay 100% of work-related medical and disability expenses 
D)  Can hold employers liable for additional amounts that result from court decisions

Question 16

Determine whether the following statement is true or false: The NCQA has established a Physician Organization Certification (POC) program for the purpose of certifying medical groups and independent practice associations for delegation of certain NCQA standards, including data collection and verification for credentialing and recredentialing.

Accepted Answer

A) True 
 B)False

Question 17

The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

Accepted Answer

A)  A small health plan needs fewer physicians per 1,000 than does a large plan. 
B)  A closely managed health plan requires fewer providers than does a loosely managed plan. 
C)  Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs. 
D)  Medicare products require fewer providers than do employer-sponsored plans of the same size.

Question 18

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

Accepted Answer

A)  In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan. 
B)  Typically, case managers for workers' compensation programs are physical therapists. 
C)  Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs. 
D)  Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

Question 19

The Ionic Group, a provider group with 10,000 plan members, purchased for its hospital risk pool aggregate stop-loss insurance with a threshold of 110% of projected costs and a 10% coinsurance provision. Ionic funds the hospital risk pool at $40 per member per month (PMPM). If Ionic's actual hospital costs are $5,580,000 for the year, then, under the aggregate stop-loss agreement, the stop-loss insurer is responsible for reimbursing Ionic in the amount of

Accepted Answer

A)  $30,000 
B)  $270,000 
C)  $300,000 
D)  $702,000

Question 20

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Accepted Answer

A)  Require a medical examination prior to accepting an application for employment 
B)  Include in the employment application questions pertaining to health status 
C)  Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges 
D)  Require applicants to answer questions pertaining to the use of drugs and alcohol  21

Exam 4: Network Management